6 min|Dr. Maya Kuczma
Debunking SIBO MythsEducation, Gut Health
Bacteria is no longer badWhile we historically demonized bacteria as the root of what ails us, our understanding has shifted with the discovery of trillions of bacteria that inhabit our gut, mouth, nose, skin, and other various tissues within the body. We now recognize that we need multiple bacteria, of a variety of species, for health of the gut, nervous system, and immune system.
However, with the discovery of Small Intestinal Bacterial Overgrowth (SIBO), another factor must be considered: location. SIBO is a result of bacteria within the wrong place - the small intestine - resulting in a variety of symptoms, such as diarrhea, constipation, bloating, loss of appetite, abdominal pain, weight loss, and malnutrition. As SIBO becomes better understood, our treatment methods are also changing. It’s time to demystify outdated information and misguided treatment plans.
Myth #1: SIBO is RareSince SIBO is not yet tested for and treated by conventional medical doctors, it may be thought of as a rare or controversial condition. However, research indicates SIBO may be responsible for up to 78% of IBS cases. (1) Intestinal fluid aspiration is considered the gold standard test for SIBO, but has yet to be incorporated as a standard gastrointestinal diagnostic test within Canada. (2) Due to this absence of mainstream testing, SIBO may not be considered as a diagnosis unless a patient visits a practitioner familiar with SIBO, who has incorporated SIBO breath testing, a less invasive alternative to intestinal fluid aspiration, into their practice.
Due to the bacterial nature of SIBO, it would be easy - but incorrect - to categorize this condition as an infection. In fact, it can be thought of as bacteria gone rogue, or misplaced bacteria. In cases of SIBO, typically benign or healthy bacteria of the large intestine move into the small intestine. Alterations in the small intestine are required to allow it to become hospitable to these bacteria, enabling bacterial overgrowth. Viewing it as an infection simplifies the complex processes that allow for this overgrowth, and may falsely imply that antibiotics or herbs alone are a sufficient treatment.
Myth #2: SIBO is an Infection
Myth #3: SIBO Can be Treated with Diet AloneIf you Google ‘SIBO’, you will likely come across SIBO-specific diets, as well as an emphasis on the low-FODMAP diet. The goal of these diets is to remove the preferred food source for bacteria in the small intestine. However, bacteria consume multiple compounds beyond the starches limited in a low-FODMAP diet; as long as they are receiving any nutrition, they can stick around, populating the small intestine. Additionally, diet alone does not address the root causes that enabled the development of SIBO. Lastly, depriving bacteria of the majority of their food source may cause them to become dormant and encapsulated within biofilms, decreasing the efficacy of our predominant treatment options (more about this below!).
Providing the bacteria with less nutrition may provide some symptom relief, and may be a viable option for patients who, for whatever reason, cannot take on a complete treatment plan. But there is currently no research to suggest that diet alone can cure SIBO.
Myth #4: SIBO Can be Treated with Probiotics
Since SIBO isn’t an infection, and cannot be considered an imbalance of good versus bad bacteria, probiotics are unlikely to treat SIBO. Additionally, since SIBO involves an inappropriate relocation of bacteria, probiotics could actually worsen symptoms if the probiotic bacteria remains in the small intestine, exacerbating the current overgrowth. One of the hallmark clues for practitioners attempting to diagnose SIBO is a patient revealing that they feel worse following probiotic ingestion. Yeast-based strains, such as Saccharomyces boulardii, or soil-based probiotics, may be utilized during treatment due to a decreased likelihood of them inhabiting the small intestine; (3,4) however, many practitioners recommend waiting until the later stages of treatment to begin to introduce additional bacteria.
Myth #5: SIBO is the Root Cause of Many Health Conditions
Since SIBO is considered to be the cause of a variety of digestive symptoms, many health practitioners falsely assume that eradicating the bacteria is sufficient treatment. However, SIBO itself has a variety of root causes; without treatment of these, SIBO can easily return.
Typically, gut bacteria is kept in check by multiple features of the digestive tract, including acidic secretions from the stomach, secretion of bile from the gallbladder, secretion of enzymes by the pancreas, immunoglobulins in the small intestine, and the ileocecal valve, a one-way valve connection between the small intestine and large intestine. Deficiency in production of stomach acid, bile, and enzymes can allow for bacteria to overgrow in the small intestine, resulting in SIBO. Additionally, anything that alters the immune system and microbiome within the gut, such as stress, antibiotics, immunodeficiency, C-section birth, lack of breastfeeding as an infant, can predispose to the development of SIBO. (5)
Factors that disrupt gut motility can also set the stage for SIBO; a lack of movement throughout the gut can allow bacteria to move upwards from the large intestine to the small intestine. Specifically, disruption of the migrating motor complex (MMC), a pattern of electrical activity in the gut that occurs between meals enabling flushing of bacteria from the small intestine into the large intestine, can allow for the development of SIBO. (6) Many factors can interfere with gut motility, including vagal nerve dysfunction; (6) infections such as Shigella dysenteriae, Campylobacter jejuni, and Escherichia coli; (7) frequent meals; (8) and narcotics.(9)
Myth #6: SIBO is Easy to TreatContrary to what some articles and health bloggers claim, SIBO is incredibly challenging to treat. In part, this is due to the myriad of causes of SIBO, all of which need to be corrected in order to ensure that SIBO treatment is effective, and long-lasting. Additionally, the bacteria involved in SIBO can enclose themselves in a sticky protective coating, known as a ‘biofilm’. Microbes form a biofilm in order to protect themselves, enabling invasion of their host - you. Within hours, a single bacterium can create this sticky coat and begin to replicate. Channels are created within the biofilm, allowing wastes to move out and nutrients to move in. (10) This shell enables bacteria to become incredibly resistant to both antibiotics and antimicrobial herbs. Treatment failure is likely due to biofilms. Research suggests up to 80% of infections may be due to biofilms, indicating that treatment of biofilms is likely an essential component of an effective treatment plan. (11)
It is due these biofilms, and the complex etiology of SIBO, that a complete treatment plan typically involves, at the very least, biofilm busters, antibiotics and/or antimicrobial herbs, stress management, digestive support, prokinetic supplements or medications, and dietary changes.